DIP Episode 504 - A Super HY Discussion of Some USMLE Concepts + Testing Considerations (Step 2/3 Rapid Review Series 110)

Welcome. My name is Divine. This is episode 504 of the Divine Intervention Podcast. So these podcasts were going to be contained in the Rapid Review series for the USMLS Step 2, CKN Step 3 exams. It's going to be series 110, series 110. So what if they give you a question about a patient and they tell you that this patient took a bunch of ecstasy and this person has been at a dance party for a few hours. But that the person sees the return from the dance party. They become some of the length, you know, very responsive and your tool that the urine production has been very, very red. What electrolyte abnormalities you'd expect in this person? Well, this is actually quite a simple question, right? So this person has literally burned up their muscles big time, right? You take ecstasy because you want to feel good when you go for some of these rays and whatnot, right? So you dance for a couple of hours. Well, guess what your muscles cells are going to start breaking down. What are some other ways they could test this? They could test this in a person that just ran a marathon, right? They could test a pretty similar concept in a person that has neuroleptic malignant syndrome, right? Obviously, the person must have been exposed to some kind of neuroleptic. The person must have been exposed to some kind of anti-psychotic, although you know that they love this diabetes, metacropromide, gastroperesis, a business for that as well.

And then they could also test the same thing in a person that has malignant hypothermia. These are all situations where muscle cells are going to break down pretty aggressively. As those muscle cells break down, you're going to get into quite a bit of trouble. So remember, potassium is an intracellular ion, right? So this person clearly has rabidomyelosis, right? So potassium is an intracellular ion. So as your muscle cells are breaking down, that intracellular soup has been released into the bloodstream. So the USML is they can give you a question about a rabidop patient. And then in the question, they'll show you an ekegis. You see these topic, T-waves, or you see a widening of the QRS concept. Of the QRS widening of the QRS, you know, I don't know if this is where it is not coming to my mind right now. But the QRS intervals widened and then they can ask you what's the mechanism, right? And again, the answer there is going to be increased release of intracellular ions, increased release of intracellular ions. And so if you're wondering, define why is potassium and intracellular ion? Well, it actually makes a lot of sense. There's this thing that uses about 70% of the energy of more cells. As long as the sodium potassium, ATP is pump. And what does this pump do? Well, this pump, it takes three sodiums out of a cell and it puts two potassiums into the cell.

So because you are constantly expanding energy, literally dropping potassium into cells, it then makes sense that if that cell membrane is disrupted, you're going to release a lot of potassium into the bloodstream and that can cause hyperkalemia, right? And again, remember, if a person has ekegis findings that are consistent with hyperkalemia, what's going to be your first step on your exams? Well, your first step on your exams is you're going to go ahead and give them calcium gluconite. Although, our friends at the USM Ls, sometimes they won't put calcium gluconite as an answer. They'll put some other kind of calcium salt. I remember the gluconite is the anion part of the calcium gluconite, right? So basically, they can even give you calcium chloride as the treatment on exams. So just kind of be mindful of that for your test. Kind of be mindful of that for your test. And there's something I'm going to say actually at the end of today's podcast that I think is kind of important for people that are getting them to take steps to answer them three, especially in recent times. Okay, so we've talked about the potassium. People that have abdominal analysis, the potassium is going to shoot up. And then another thing you're going to see in abdominal analysis is that it's all going to have hyperphosphatemia, hyperphosphatemia. Because again, think about it. What's selling your body? Is this like a ridiculous amount of ATP? You don't get me wrong, your heart is there. That's fine.

But don't forget that your muscle cells also use a lot of ATP. So they continue to tone of phosphate. All that phosphate can be released into the bloodstream, right? And if that phosphate is released into the bloodstream, then that phosphate combined up calcium. So that leads us to the next electrolyte abnormality. The person is going to be high bull calcemic. Because remember, phosphate and calcium, they love each other, right? So they bind each other up pretty strongly. So the person's phosphate is going to be high. The person's calcium is going to be low. Okay, the phosphate is going to be high. The calcium is going to be low. And remember for raptomyolosis, what are you going to find on your analysis? Well, remember, on your analysis, you're going to see a ton of blood. But when you're in my cross-sculpe, you're not going to find rib blood cells. You're not going to find rib blood cells. Again, I've said this many times on this podcast, but with your love to go after that is they will say, oh, you saw like two, three, four plus blood or whatever your analysis. And then when you're in my cross-sculpe, they won't say no rib blood cells. No, that's ridiculous, right? Because I'm sure this is in every anchored egg known to mankind. It makes absolutely no sense to test things like that if you're the USML. So what's the smart thing they're going to do? Well, the smart thing they're going to do is they're going to put like 0 to three rib blood cells per high power field, right?

So mitz to think that always expect the perfect questions on the exams. They're going to be like, who? 0 to 3. Well, 0 to 3 rib blood cells per high power field. Well, maybe there's some, they're starting to know these assumptions, they're getting trouble. No, okay? If a person has like two, three, four plus blood, you're going to see multiple rib blood cells on a high power field. It's not going to be 0 to any thing. It's going to be like some defined number like 20, 30 or something ridiculous, right? So this person has wrapped up that those, the blood you saw on your analysis is actually my own blue bit. The blood you saw your analysis is actually my own blue bit, right? But let me ask you this, what are some things that can cause you to see frank and obviously like maybe before we jump into that? How do we show the rabbit one? I'll say, flow it's, flow it's, flow it's, right? Flow it's, flow it's, flow it's, flow it's, flow it's, flow it's, flow it's, give them all sailing is going to flush the, it's going to flush the, what is it called? The Mayo Globine, throw the person's kidneys so that the person's kidneys don't get damaged, okay? It's going to flush it through the kidneys so the kidneys don't get damaged, so the kidneys don't get damaged. And what are things though that can cause you to have like actual red cells on your end microscopy on your exams? Well, a couple of things, first one easily can be a person having an acute hemolytic transition reaction, right?

Acute hemolytic transition reaction, uh, this is pretty much from ABU incompatibility, right? So you get red cells that don't really match up. So let's say for example, your person that has a blood group A and you're getting blood from person that has blood, blood group B, well that's clearly going to be a problem. And maybe like divine, why would that clearly be a problem? Well if you're blood group A, that means you have anti-B antibodies, right? If you have blood group A, that means you have the A antigen on your red blood cells, so you don't have the B antigen, well since you don't have the B antigen, guess what you're going to do? You're going to make auto antibodies, right? Your body, your body, your not auto antibodies because you're not making antibodies against yourself. You're going to make antibodies, that's what you're supposed to do. You're going to make antibodies against the B antigen. So you're going to have anti-B antibodies. So if you get blood from a person that has the, you know, blood group B, then your anti-B antibodies are going to attack those red blood cells. And as you attack those red blood cells, you're going to cause himolises of those red blood cells, right? So in those people, you're going to see red blood cells. If on your analysis, you're going to see blood, and on your macroscopy, you're going to see actual red blood cells, you're going to see actual red blood cells. Right?

That's why many times when people have acute hemolytic transition reactions, they tend to have flank pain, they tend to have flank pain. Why? Because again, all that stuff is going towards the kidneys. That's why again, the management is the same. You're going to go ahead and give those people fluids. You're going to go ahead and give those people fluids. And remember, when a person has an acute hemolytic transition reaction, what kind of hypersensitivity reaction is that? Well, it's going to be type two. So type two hypersensitivity reaction, right? Because you're forming antibodies against your red blood, against red blood cells, right? So that's going to be a type two hypersensitivity reaction. And just FYI, before I go into all the causes of actual red blood cells in a person's urine, one thing you want to keep in mind, one thing that is super high or to keep in mind, is our friends at the USML is they're very smart. They're not stupid. That's one thing people don't realize. The USML is very smart. They're absolutely not stupid. Here's what they can do to you. Instead of putting in myolosis, they can see, oh, which of the following is the mechanism behind the patient's flank pain? Right? Obviously, it will be great if they put a ruptomyelosis as an answer. So that's what they do a lot of the time, but not all the time. It will be great if they put all hemolosis of red blood cells as an answer. But again, they do that most of the time, but not all of the time.

What is something they do sometimes to replace ruptomyelosis as an answer? On the exam, they'll put a cutabula necrosis. Because remember, ruptomyelosis causes ATN. It's one of the common causes of ATN. It's one of the common causes of ATN. Although if I'm not mistaken, I'm pretty sure that pre-rinolyzotemia is the most common cause of ATN of acute tuberculosis. So just be careful. Again, the USML is they're very big on using surrogates, very big on using surrogates. I wonder why do they use surrogates? Again, we live in an on-key generation. Many people these days apply a drive-thru mentality to learning. They just want to memorize the fact and move on. They don't applaud and choke on an exam. So these days, most of the many USML answers, they are pathophased answers. They're not like straight answers. They are more pathophased answers. So if you don't have the understanding, or you're not able to see the concept in a few different dimensions, you're really going to struggle on those. That's why you see some people, they say, oh, I finished this on-key day. My score is on my, I didn't do as well as I hoped on my exam. Again, what's the limiting factor there? It's a lack of understanding. It's a lack of understanding and a lack of the ability to see things in many different dimensions. Okay, let's go back to this. One of some other things that can cause red blood cells in a person's urine.

Well, what if they give you a question about a person that has a history of osteoarthritis? And you notice that man, they have a lot and they've been on chronic, you know, pharmacotherapy. And you see, there's a lot of red blood cells in the person's urine. Well, if you see something like that, I want you to think of a person that has renal papillary necrosis. Renal papillary necrosis. I remember people that have osteoarthritis, they can be an acetylaminophen, they can be an inset chronicly to help with the pain. But the thing is, those things can be directly toxic to the renal papilla. And as those renal papillary cells slough off, that's going to cause a lot of problems. It's going to cause a lot of problems, right? So you're going to see like red blood cells in the person's urine, person's creatinine is going to go up a little bit. That's renal papillary necrosis. Although remember, people that have sickle cell disease, I'm going to say that again, people that have sickle cell disease, even people that have sickle cell trait, right? Sickle cell trait can also have renal papillary necrosis. Okay, and then what if they give you a question about a person that has blood in their urine, right? And you're in my cross-combatuals red cells. I noticed that this person is hypertensive, this person has periodical edema. And you notice that this person has, you know, so mildly demofi alloys tremolese and whatnot.

Well, I really hope you think about nephrodix syndrome, I really hope you think about nephrodix syndrome. That's something I kind of want to point out here. Many times nephrodix syndrome, you're not only going to see red blood cell cast in your urine, you're going to see front grade blood cells. You're going to see front grade blood cells. Remember, it's very unlikely that an effrodix syndrome question will have actual red blood cells in the person's urine. Okay, it's very unlikely that an effrodix syndrome question is going to have actual red blood cells in the person's urine. Okay, so please just kind of keep these things at the back of your mind as you're studying for your exams. Another cause of, you know, actual blood, actual red blood cells in the person's urine, I mean, they can give you a question about a person that they tell you that they've noticed that for the last two months, you know, they've been losing some weight. And that one testicle has been more edemotus than the other. Now friends of the US and the US men, these people are smart. So like, this person has been losing weight. They can even tell you that this person has, you know, like some police, like themia. And then they tell you that one testicle appears to be more edemotus than the other. And then, you're told that, you know, on physical exam that the person's left testicle appears to be a demotus, but the right testicle is not.

When you see stuff like that, what are beautiful for, and you see red blood cells in the person's urine? What are they tested? That's pretty straightforward, right? This is going to be renal cell carcinoma. You're like, wait, what? Yeah, it's renal cell carcinoma. Okay. So let's make all the integration that we need. And I just want to find out, one testicle, the left testicle will be more edemotus than the right testicle. That's weird. The person is losing weight. The person has police, they have beenia, dude, like, what are you getting after? Well, let me explain. First things first, first things first. Remember, one tell, sign of renal cell carcinoma, especially in the left kidney, is when the person has a left-sided varicoseal, a left-sided varicoseal. Now, if you expect that the USML is going to come out and say bag of worms appear in the left testicle, good luck to you. You're probably taking a, kind of a different exam compared to what the USML is actually are, right? That is not what they're going to do anymore. All these boss words, boss phrases have largely, they're like dinosaurs on the USM Ls. They've largely become extinct, right? So just kind of get your head out of that, right? But again, instead of saying bag of worms, right? What is the simple thing they can do? They can just tell you that you have a testicle that appears edemotus, right? Kind of keep that at the back of your mind. Keep that at the back of your mind, right?

So that person, this person pretty much has a left-sided varicoseal. So let me ask you this, why will a left-sided renal cell carcinoma cause a left-sided varicoseal? Makes a lot of sense, actually, right? In fact, pretty much tells you that this person's left-sided renal cell carcinoma has likely spread to the left renal vein. Because if you remember, this is one of those throwbacks from Step 1 that are wonderful friends at the MV Ms, love to test on Step 2 and Step 3. What is that throwback? Is the drainage patterns, the drainage patterns for the right and the left side? Remember on the right side of the body, your right renal vein drains directly into the AVC, your right ovarian vein drains directly into the AVC, your right testicle vein drains directly into the AVC, your right adrenovane also drains directly into the AVC. But that is not the case on the left. On the left, things are pretty weird, right? All these things I mentioned drain into the left renal vein on the left side of the body. So your left adrenovane drains into the left renal vein, your left testicle vein drains into the left renal vein, your left ovarian vein drains into the left renal vein, and then the left renal vein will collect all that information crosses in between the order and supermaizentary cadre and then goes to the right side of the body and drains into the AVC.

So if the person has renal cell carcinoma that has literally involved the left renal vein, all those things that drain into the left renal vein, they're not going to drain very easily. In a man, are you going to see symptoms because your left adrenovane is not draining? No. The thing that's going to be readily apparent on physical exam is going to be a left sided varicoselle, right? It's going to be a left sided varicoselle. And let me tell you another question that Gleer just came to mind that our friends at the MBM Es can throw them there. Do you know another question they can ask? They can even say, you know, they can tell you that, ooh, this person is patient has like, again, they will give you the adenosine left testicle, right? And then they will say that the patient is diagnosed with they'll give you a bunch of symptoms, right? They'll tell you weight loss, polycythemia, blah, blah, blah, blah, blah. And then they will tell you which of the following physical exam findings is most consistent with metastatic renal cell carcinoma. If you see that, it's going to be the presence of that left sided varicoselle, right? The thing is, the USML is these days, I kid you not, I kid you not. They love to ask many questions based on physical exam findings. I don't know how to put this. Let me, let me try to state this a different way. And this is one reason why I like to emphasize these things in many of my reviews and review courses.

But they'll give you a disease process, they'll give you a bunch of symptoms that the person has, right? And then they will say which of the following is most consistent with this physical exam finding or which physical exam finding is most consistent with xyz disease process, right? You're going to notice this a lot on step two, step three, they'll say, oh, they'll give you something and then they'll just have this innocuous physical exam finding question, right? Like, for example, I give you a bunch of symptoms. I said, oh, the person has polycythemia, the person has a left sided varicoselle, the person has weight loss, right? The person has this, the person has that. And then I asked which of the following physical exam findings is most consistent with metastatic disease or is most consistent metastatic renosylcorsinoma? Basically, they essentially make an abiot starts question out of that. Really? Yeah, they are because they are pretty much asking you of all these things which one is most specific for metastatic renosylcorsinoma? Well, it's not going to be weight loss. It's not because there are many things that can cause weight loss besides metastatic renosylcorsinoma. Two, it's not going to be polycythemia. There are many things that cause polycythemia. I mean, I can literally give you a pretty solid list. In fact, maybe let's make that the next rapid review a question, right? But there are many things that can cause polycythemia, right?

But that left sided varicoselle is pretty striking, especially in the patient with all these risk factors, right? So in that case, we're going to go with the left sided varicoselle, right? Because again, why would that left side varicoselle be so specific? Well, the reason is so specific is that by seeing that you know for sure that, oh, this renosylcorsinoma has gone to the left renovate, right? It's no longer localized to the kidneys anymore. It has now gone to the left renovate. And let me ask you this. Do you see why renosylcorsinoma many times when it's diagnosed is usually metastatic already? Yeah, because it's just so virulent, right? Because it has this in root directly into your inferior vein, through that left renovate, right? And then from there, it can begin to, because you may wonder, why do you think that renosylcorsinomas even love to spread to the adrenos? Like, why? Why do you think that's the case? I don't know, maybe because the left adrenovate drains into the left renovate, right? So again, these are all things you should be able to integrate and make connections with on your exam.

Again, this fiscal exam finding thing, I promise you it's a very common construct that the USM is love to use these days in question, because it's just one of those kinds of questions that you actually have to reason pretty deeply to arrive at the answer, because it's almost like a critical thinking in a real-time question, because these are things that I can almost promise you, there's probably no review resource that covers this, right? And it's really hard for review resource to cover this, right? Because it's almost like a mixture of bio stats and pretty much any subject that catches the offancy on that giving day. So you're just going to keep that at the back of your mind as you prepare, right? So this person has, you know, metastatic renosylcorsinoma causing that varicosell, right? Because again, if it involves the left renovane, then the left esticula vene is not going to drain properly. And the left esticula drain does not drain properly, then blood is going to stop backing up. It's going to stop backing up in the blood vessels, right? Especially like in your pump-in-if-farm plexus, remember the pump-in-if-farm plexus is a network of veins that drains the kidneys, right? It's a network of veins that drains the kidneys, a network of veins that drains the kidney. I mean, sorry, not the kidneys, the testicles, and network of veins that drains the testicles, okay? And network of veins that drain the testicles.

So if that pump-in-if-farm plexus is having a backup of blood, right? You're raising the hydrostatic pressures within those vessels, you're going to have some kind of fluidic travestiation. That's going to cause a dima of the person's left testicle, right? So the person is going to have a left-sided varicosell. And now you may wonder, divine, why does this person have polysiphemia? Well, remember renosylcorsinomas, remember, smoking is the biggest risk factor for renosylcorsinoma, right? But renosylcorsinomas have this nasty habit of making evil in a pyranyoplastic fashion. As you make that viewpoint, in that pyranyoplastic fashion, that's going to cause quite a number of issues, right? The big one being a polysiphemia, the big one being polysiphemia, okay? So I'll encourage you before we continue to the next question, really, really make sure that your person that aims to understand, aims to critically think, and aims to integrate. We're going to say that again, make sure you're a person that aims to understand, that aims to critically think, and aims to integrate. If you're a person that is using Anki, Anki is phenomenal. This is me saying it. Anki is phenomenal. Anki is amazing, but please make sure that those things you're on-kin and those things you are memorizing, that you actually understand, you actually can critically reason with that material and you can make integrations.

I'm telling you this, I feel like this we're antecedents, we started seeing, like last year, but I feel like it's going to become more and more common this year. A lot of people are beginning to fail USMLA exams these days because they are not prepared for this construct. In fact, to be honest with you, I think I'm going to make a podcast on why people fail USMLA exams. I'm literally going to make a podcast on that. Why people fail USMLA exams? I'm going to deal with this problem from many different angles, so that because sometimes it's better to study failures so that you don't fall into that same trouble. We're going to talk about that in a later podcast. I'm actually going to maybe write that down somewhere so I can remember to make a podcast on that stuff. Again, if you look the way into great concepts across multiple disciplines, I think you benefit from the review courses I have. For step one, two, step three, have three courses coming up this week. Actually, one study tomorrow, that's the two and a half hour NV Me testing in strategy class. On Thursday, I have a four hour bio-statreview and on Friday, I have a five hour social sciences, ethics, quality improvement, healthcare systems, professionalism, class. These classes are all for step one, just step three, all over Zoom. Again, they are not lectures. They are all scenarios, exam style scenarios that can really prepare for you exams. Again, if you love the way I teach, then that's what you're going to be getting.

You're going to be getting a very solid version of it during these review classes. The class on Saturday, the social sciences and ethics class, we have my 200 plus scenarios that we discuss that just touch on many different things. It's very rare for you to attend these classes and see a lot of scenarios on the exam that you're like, whoa, I've never seen these before. The next week study on Monday, we have the 20 hours step two, step three class. If you're interested in these classes, just shoot me an email through the website and I can give you some more information. Let's go ahead and continue. Renosel-Crosse-Noma, as we said, can cause blood in a person's urine. It can cause blood in a person's urine. I think we've talked about the major causes of blood in a person's urine. Now, what are some, and obviously if you have trauma, like if you have your rethral trauma or something ridiculous like that, that can also cause blood in your urine. What are the causes of evil? Let's make a few integrations here. What are some causes of elevated evil? What are some causes of elevated evil in a person? We've talked about malignancy. Renosel-Crosse-Noma, that raises evil. Remember, there are many malignancies that love to raise evil. They're many malignancies that love to raise evil. Renosel-Crosse-Noma is a very big one, but under the classic one is going to be hepatocelola-Crosse-Noma.

One thing you may ask your ex-emesis, they'll give you a bunch of labs, and they'll see which of the following is more indicative of hepatocelola-Crosse-Noma versus Renosel-Crosse-Noma. Remember, again, like I said, RCC can raise your evil. HCC can raise your evil as well. One unique feature that you're going to see that's different from RCC in HCC is that people that have hepatocelola-Crosse-Noma, you're going to see LFT abnormalities. Remember, I made an LFT podcast in episode 500 and free, I think? Yeah, I think I've been in episode 503. That's a lot of podcasts. I had to keep track of these days. And also, you're going to notice an increase in alpha-fiddle protein. That's a pretty unique feature of hepatocelola-Crosse-Noma. You're going to see an increase in AFP. Remember, AFP is the tumor marker for hepatocelola-Crosse-Noma, and it's also the tumor marker for a yolk-sac tumor. Remember, those are the things we call endodermal sinus tumors. Endodermal sinus tumors. Okay. So, Renosel-Crosse-Noma makes Epoinoprhenioplastic fashion. HCC is the low-cost endodermal makes Epoinoprhenioplastic fashion. I mean, think about a brain mass in the posterior fossa, like cerebellum area, and it's calcified, and the breast-hehas-high Epo. Again, remember, that's going to be a Von Hippolyndale with Hemanjublastomas. Maintublastomas have a solid decision for Hemanjublastomas love to make Epoinoprhenioplastic fashion. In the Pernioplastic fashion.

So, those malignancies can cause polycyphemia from elevated Epo. Well, remember, Epoin is also going to be elevated in a person that has chronic hypoxia for any reason, literally chronic hypoxia for any reason. In fact, like there are two big categorizations of causes of high Epo. One is from malignancy, which I've talked about. The second big categorization is from chronic hypoxia for any reason. Like, literally, they can make an Epo question of the following things I'm going to talk about. They can give you what should be true of Epo levels in a person that has cystic fibrosis. C cystic fibrosis is going to cause fibromyroidic lung disease over time. That fibromyroidic lung disease is going to cause hypoxia. That hypoxia is going to raise your erythropoetin. They can give you a question about a person that has COPD. They can tell you that, ooh, this person, they can say they can basically like give you a vignette that shows COPD exacerbation. But then they'll give you a bunch of labs and then they'll ask, what is the mechanism behind the polycythemia in this person? And then it's going to be from elevated Epo production, or they can say, you know, chronic hypoxia blah, blah, blah, blah. Again, there are many ways they can test those things. So, they can give you like a person that has COPD. The person can also have elevated Epo because of that chronic hypoxia. They can even tell you, give you a question about a person that has, like one of these numoconealcy's, right?

Again, all those things are going to cause fibromyroidic lung disease. They're going to cause chronic hypoxia. That's going to elevate the person's erythropoetin. So, again, these are always that they can go after these things on exams. Again, any cause of chronic hypoxia can raise your Epo. In fact, one of the more ridiculous avenues where they test something like this is where people that have not a congenital heart disease. Like, for example, they can give these x-ray images of like the terrible teas, right? And again, I will encourage you, make sure you can identify the images of those terrible teas. You want to be able to identify things like tetralogy of the low on a chest x-ray, right? They're going to have like a bud-shaped heart. You want to be able to identify things like transposition of the grid vessels, right? Things like total and non-alos coronary venous return. These are things you want to make sure you're able to identify. These are things you want to make sure you're going to be able to identify on exams, right? So, they can ask you, again, we'll be through Epo levels in these people, right? Again, it's going to be high, right? Because those will have a sanitary congenital heart defect, right? Again, you can just see, I'm just really trying to impress like review content with you, but I'm also trying to like really emphasize some things you want to be thinking about as you're preparing for these exams. These exams is not about just like reviewing resources.

No, you also have to review resources strategically. You have to think on what you're learning strategically. Again, that's kind of like the name of the name of the game, right? That's kind of the name of the game, right? And maybe like the final if I just review my resources, I can get in the 230s. That's true. You're probably going to be able, right? Work hard getting the 230s, right? But if you want to start going into the higher score ranges, the high 240s, 255s, 266s, these little strategic things here and there, these are things you need to kind of have down, down, pot, right? These are things you need to have down, pot. Now remember, it's not every polysiphemia that is associated with high evil. It's a common area where many people make it is not every polysiphemia that is associated with high evil. I'm going to say that again, it is not every polysiphemia that is associated with high evil. Hmm, what could cause that? Well, the classic one, old person, usually a male, right? And this person has like aquagenic paritis. The person has aquagenic paritis. They tell you that this person has very high blood pressure, right? That is not very responsive to anti-hypertensives. And the person has chronic headaches, has all these nose bleeds. When you see something like that, I would really hope you're thinking, oh, divine, this is polysiphemia vera, right? This is polysiphemia vera. Remember, p vera is a myeloproliferative disorder.

And typically, this arises from a jab to mutation. Well, you have a jab to mutation. The thing that's going to happen is that it can cause many different problems, right? But one thing you can cause is over proliferation of your red blood cells. And that can cause you to have polysiphemia, right? So you may wonder, divine, why does this person have high blood pressure? That doesn't seem to respond very well to anti-hypertensives. Well, think about it. Just go back to this fancy thing you learned from step one, a non-as-poisell's law, right? Poisell's law. Remember, in Poisell's law, the peripheral resistance, right? The resistance is directly proportional to the length of the vessel, directly proportional to the viscosity, and inversely related to radius to the fourth power, radius to the fourth power. Hmm. Well, if you have polysiphemia, what do you think it's going to be true of your blood viscosity? Well, your blood viscosity is going to go up, right? It makes sense. Your blood viscosity is going to shoot up. If your blood viscosity shoots up, guess what? Then your peripheral resistance is going to go up. Guess what? What is that going to cause? That's going to cause a person to have hyper tension, right? Because the peripheral resistance is going up, right?

In fact, believe it or not, our friends at the NBM Es, they can give you a question about a person that has p-vera, and then they can tell you that this person, you know, on physical exam, the person is noted to have an S4 heart sound, right? And this person, they can tell you that, oh, this person has poly control, poly control p-vera. What's the mechanism behind that S4 heart sound? Well, it's from a chronically elevated cardiac afterload. It's from a chronically elevated cardiac afterload. Again, why? Because again, your blood is very viscous. You have this chronic increase in total peripheral resistance, and that increase in total peripheral resistance is making it harder for the left ventricle to eject blood, right? So that's creating a chronic pressure overload situation on the left ventricle. So your myocardium is going to try to build succumbures in parallel, right? So that you can generate more force, more oomph, to push those pushed up blood out of the left ventricle, right? Whenever you have chronic pressure overload, that's going to cause concentric hypertrophy of the left ventricle. That's going to create an S4 heart sound, going to create an S4 heart sound, right? And remember, so people that have polysethemia, p-vera, the array blood cells rise a lot, not from Epo, but from like a different mechanism, this is Jack II mutation. So those, those crazy, crazy amounts of red blood cells is actually going to suppress their Epo production.

So people that have p-vera, they have polysethemia, but their Epo levels are extremely low, their Epo levels are extremely low, okay? Their Epo levels are extremely low. That's something you want to keep at the back of your mind, for example. And I guess as a bonus, to keep in mind is, again, why may you see hypertensive symptoms, you know, they may give you some question about a person, they tell you that this person has been having recurrent infections, right? Recurrent infections. And then they tell you that you notice that this person has a hip-like, you know, they have like a cervical lymphatonopathy and they tell you that bone marrow biopsy, you know, demonstrates the diagnosis, the presence hypertensive, the person has these chronic headaches, right? And they tell you that you see like a monoclonal expansion, right? On, you know, testing of the person's bone marrow specimen. If you see this, I'll really hope that you're thinking, probably thinking of, or they tell you that you see a lot of pentamur, right? On, you know, testing, you see a lot of pentamuric immunoglobulins on testing of this person's blood smear or bone marrow sample, right? In this case, you want to think about Waldenstroms, macroglobulinemia, Waldenstroms macroglobulinemia. Remember, this is kind of like, it's almost like a pre-multiplemyloma. Many times they won't have the crap symptoms that we see multiplemyloma, but they have a lot of IgMs, right?

They have plasma cells that are just making like a ridiculous amount of IgMs. And remember, IgM is the biggest antibody, right? Most times it has like pentamur, right? So because it's so huge, if you have plasma cells that are just pumping out a ton of IgMs, ton of IgMs, ton of IgMs, they're going to raise the viscosity of your blood. As you raise the viscosity of your blood, that's why you have these are classically described hyperviscosity symptoms associated with Waldenstroms macroglobulinemia. Because don't get me wrong. Why is it, you may wonder, like divine, can't we get the same thing from other multiplemyloma-like things where it's IgG that's elevated or IgG that's elevated or whatever. Not really, right? Because IgG is a monomer, right? IgE is a monomer, right? But IgM is a pentamur, right? That's like 5x antibodies, right? That's a lot. Those things are going to really make your blood super, super viscous. If your blood is super, super viscous, then guess what? You're going to have a lot of issues. Literally, you're going to have a lot of issues, right? That's going to, again, raise your peripheral resistance. It's going to cause hypertension, right? And again, that's why it's going to have headaches, right? Because there's a lot of vascular congestion with all those IgMs, right? And all those things. So it's going to cause headaches. They're going to have nose bleeds. Sometimes they have like renounce phenomenon, right?

Because they have poor profusion of their digital orders, poor profusion of their digital orders. Okay, I think I'm going to, I'm going to go ahead and stop here now. But again, this podcast, you know, it's a rapid review series, but I think I may put something at the end that says that guys, this is one of your three words like listen to this stuff is actually pretty, pretty high, you know, for the exams. And I said, I'm going to say one thing about the USM at least these days, especially step two, step three, expect long question stems. I think that's something that kind of behooves people. Expect long question stems. That's all I'm going to say. Expect what? Long question stems. Question stems are not very short these days. Expect long question stems. For those of the new teams, that just expect expect again, long question stems. That's all I'm going to say. Okay, again, as I wrap up, I offer one or one to learn for all the USMLA exams, step one to step three, pre-clean cool medical exams, third year clerkship shelf exams, I have review courses for step one, step two, step three. I have a series of courses literally starting tomorrow. If you want more information, I should give an email. I have a 100 hour step two, step three course coming up, till end of April, and then a good chunk of May, very high level course. Let me tell you an attendance.

I cannot accept everyone that wants to participate in the course because again, I want to be able to invest in everyone that attends that course. And then we also have this podcast on Apple, Google and Spotify, I have a You Tube channel you can check out, I have a bunch of videos on there. And then I have another website called our Divine Intervention Life Lessons.com. Divine Intervention Life Lessons.com. That's a website where from a biblical perspective, I put two life lessons every week. Again, I think we have like 246 episodes now. Many people have listened to those podcasts, found it to be extremely helpful. Actually, those podcasts also on Apple podcasts have a Divine Intervention Life Lessons podcast on Apple podcasts. So, just check those things out and also help with your applications and things like that, like review your application, do your mock interviews and prepping you so that you can be a person that is a competitive applicant. So, if you're interested in any of these things, just ship me an email and give me some more information. But thank you for joining me today. Again, I hope you find this podcast to be helpful. Honestly, this is probably one of my highest yield rapid review series, right? Because we need to just talk about concepts. We talked about lots of integrations, but also a lot of just strategy with exam questions. So, I will see you in a episode 505. Have a wonderful rest of your week. God bless you and bye for now. Thank you.

Hyperkalemia (K+ is an intracellular ion released into the bloodstream).

Hyperkalemia, hyperphosphatemia, and hypocalcemia.

Calcium gluconate (to stabilize myocardial membranes).

Type II hypersensitivity reaction (antibody binding to foreign antigens).

Left-sided varicocele.

Extremely low/suppressed (because the high RBC count suppresses EPO production).

IgM pentamer.

Phosphate released from muscle breakdown binds with calcium (Ca2+).

Osteoarthritis/Chronic NSAID use, or Sickle Cell Disease.

Nephrotic syndrome typically shows red blood cell casts; AHTR may show actual RB Cs (if severe).

JAK2 mutation.

Alpha-fetoprotein (AFP).

Because the left renal vein collects drainage from multiple structures, and obstruction suggests local spread of the tumor.

Increased blood viscosity due to high levels of IgM pentamer.

Phosphate released from muscle breakdown binds with calcium (Ca2+).

Osteoarthritis/Chronic NSAID use, or Sickle Cell Disease.

Nephrotic syndrome typically shows red blood cell casts; AHTR may show actual RB Cs (if severe).

JAK2 mutation.

Alpha-fetoprotein (AFP).

Because the left renal vein collects drainage from multiple structures, and obstruction suggests local spread of the tumor.

Increased blood viscosity due to high levels of IgM pentamer.